Home birth triples neo-natal death risk: study

It doesn't appeal to everybody, but for some women, having a good birth means delivering in the peace and familiarity of their own home, far from the white glare and hi-tech wizardry of the hospital.

But a big study in an influential medical journal published today may give them pause. Home birth may be best for the woman, the study finds: she is less likely to have medical intervention, from painkilling drugs to forceps to a caesarean section. But, the researchers claim, it carries three times the risk that her baby will die.

The study in the American Journal of Obstetrics and Gynaecology will inflame passions. But, say the researchers from Maine Medical Centre in Portland, the findings must be addressed. "Women, particularly low-risk parous [having given birth before] individuals, choosing home birth are in large part successful in achieving their goal of delivering with less morbidity [damage] and medical intervention than experienced during hospital-based childbirth," they write.

"Of significant concern, these apparent benefits are associated with a near tripling of the neonatal mortality rate among nonanomalous [without birth defects] infants."

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The researchers pulled together data from studies in the US and in Europe. They considered a total of 342,056 planned home births and 207,551 planned hospital births.

The increased death rate was in neonates - babies in the four weeks after delivery. The team found double the number of deaths overall among those born at home and triple the number when they removed those with congenital defects from the calculation. The main causes were breathing problems during birth and failed resuscitation after delivery.

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Yet women who choose a home birth tend to be in good health and their babies are less often premature or of low birthweight. "It is especially striking as women planning home births were of similar and often lower obstetric risk than those planning hospital births," they write.

In the developed countries of Europe and the US, they say, after birth defects, oxygen deprivation is the next leading cause of death during or after delivery.

In the past two decades, there has been a marked decrease in babies' deaths because of a lack of oxygen during labour and delivery, they say. "Speculative explanations for the trend include more liberal use of ultrasound, electronic foetal heart rate monitoring, foetal acid-base assessment, labour induction and caesarean delivery," they write.

"Our findings, considered in the light of these observations, raise the question of a link between the increased neonatal mortality among planned home births and the decreased obstetric intervention in this group."

The editors in chief of the journal, Thomas J Garite and Moon H Kim, said the report "supports the safety of planned home birth for the mother, but raises serious concerns about increased risks of home birth for the newborn infant".

"This topic deserves more attention from public health officials," they added.

The president of the Royal College of Obstetricians and Gynaecologists, Professor Sir Sabaratnam Arulkumaran, said there was no clear picture of the relative safety of home births, because it was not possible to conduct randomised trials, where women would be allocated either to give birth at home or on the labour ward.

"The finding that the consequences for the baby are more severe needs to be carefully considered by women, policymakers and care providers," he said. "Certainly, the move towards offering women a choice in their place of birth in the UK needs to be weighed against such evidence."

But he said that a recent study in Scotland had shown that any difference in outcomes for babies disappeared if women considered at high risk of complications during pregnancy and delivery were taken out of the equation. Screening to pick up such women was important, he said, and so were arrangements to get a women to hospital if something went wrong during a home birth. "Mothers should not be alarmed as long as there is a transfer mechanism if there is a difficulty," he said.

He added that it was preferable to have two midwives with good resuscitation skills present at home - one for the woman and another for the baby. Women should also realise that one in three attempting a home birth for the first child ended up being transferred to hospital and one in 10 with a subsequent child - not only because of complications but also for pain relief.

"With the above systems in place and provided women receive one-to-one midwifery care, planned home births for low-risk women are a viable option," he said.

Mary Newburn, head of research at the UK's National Childbirth Trust, said it was "an important study that needs reviewing", but added: "NCT's own detailed review of home birth concluded that, although the quality of comparative evidence on safety of home birth is poor, there is no evidence that for women with a low risk of complications the likelihood of a baby dying during or shortly after labour is any higher if they plan for a home birth compared with planning a hospital birth."